Can bipolar medications, such as lithium, cause gingival (gum) lesions?

Bipolar Medications and Gingival Lesions

Yes, certain medications used to treat bipolar disorder can cause gingival lesions, particularly mood stabilizers like lithium and some antipsychotics through mechanisms including xerostomia, altered immune response, and direct tissue effects.

Medications Associated with Gingival Lesions

Mood Stabilizers

• Lithium: Long-term lithium maintenance therapy is associated with poor oral health, including gingival inflammation and lesions 1
• Valproate: Can contribute to gingival problems through medication-induced xerostomia 2
• Carbamazepine: May affect gingival tissues, though less commonly reported than other mood stabilizers 3

Antipsychotics

• Both typical and atypical antipsychotics can contribute to oral health problems through:
  • Decreased salivary flow (xerostomia)
  • Altered immune response
  • Direct tissue effects 2, 4

Antidepressants

• SSRIs and tricyclic antidepressants (often used as adjunctive therapy in bipolar disorder) are strongly associated with:
  • Xerostomia (dry mouth)
  • Increased risk of periodontal disease
  • Gingival bleeding complications 5

Mechanisms of Gingival Lesion Development

1. Xerostomia (Dry Mouth)

   • Most bipolar medications reduce salivary flow 5
   • Reduced protective effects of saliva lead to:
     • Increased plaque accumulation
     • Higher risk of gingival inflammation
     • Compromised tissue healing

2. Altered Immune Response

   • Some medications modify inflammatory responses in gingival tissues
   • Can lead to exaggerated inflammatory reactions to normal bacterial plaque 6

3. Direct Tissue Effects

   • Certain medications can directly affect gingival fibroblasts
   • May cause gingival enlargement or hyperplasia in susceptible individuals 3

4. Behavioral Factors

   • Bipolar disorder itself is associated with:
     • Poor oral hygiene during depressive episodes
     • Decreased self-care behaviors
     • Irregular dental visits 7, 6

Evidence of Increased Risk

Research shows that individuals with bipolar disorder have:

• 58.5% prevalence of periodontitis compared to 39.7% in controls (OR = 2.13) 6
• Higher bacterial loads associated with periodontal disease 6
• Significantly increased risk during depressive phases (OR = 28.94) 6

Management Recommendations

1. Regular Dental Monitoring

   • More frequent dental check-ups for patients on bipolar medications
   • Special attention to gingival tissues during examinations

2. Enhanced Oral Hygiene

   • Intensive oral hygiene instruction
   • Consider prescription-strength fluoride toothpaste
   • Recommend alcohol-free antimicrobial mouth rinses 4

3. Medication Considerations

   • When possible, consider medications with lower risk of oral side effects
   • SSRIs with lower anticholinergic effects may cause less xerostomia 2
   • Avoid combining multiple medications with similar oral side effect profiles

4. Treatment of Xerostomia

   • Saliva substitutes
   • Sugar-free gum to stimulate saliva production
   • Adequate hydration

5. Coordination of Care

   • Consult with the patient's psychiatrist before prescribing NSAIDs or other medications that might interact with bipolar medications 7
   • Consider potential drug interactions when planning dental treatment

Clinical Pearls

• The depressive phase of bipolar disorder shows the strongest association with periodontal disease 6
• Patients with bipolar disorder often have poor oral hygiene, extensive dental caries, and numerous missing teeth 1
• Higher levels of periodontal pathogens (A. actinomycetemcomitans and P. gingivalis) are found in bipolar patients with periodontitis 6
• Always consider the potential for medication-induced bleeding complications when planning invasive dental procedures 5